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Frausto v. Yakima HMA, LLC

Supreme Court of Washington, En Banc

April 27, 2017

RUDY FRAUSTO, Appellant,
YAKIMA HMA, LLC, a Washington State Corporation, Respondent.

          YU, J.

         The sole issue in this case is whether advanced registered nurse practitioners (ARNPs) are per se disqualified from testifying on proximate cause in a medical negligence case. For the reasons discussed below, we hold that ARNPs may be qualified to testify regarding causation in a medical malpractice case if the trial court determines that the ARNP meets the threshold requirements of ER 702. The ability to independently diagnose and prescribe treatment for a particular malady is strong evidence that the expert might be qualified to discuss the cause of that same malady. We therefore reverse the trial court and remand for further proceedings consistent with this opinion.

         Factual and Procedural History

         Rudy Frausto, a 70-year-old quadriplegic man, checked in to Yakima HMA LLC for pneumonia. While there, the nurses allegedly failed to provide proper care in the form of moving him, turning him, and providing him with an appropriate bed. As a result, Frausto developed pressure ulcers and filed suit against the medical center.[1]

         Yakima HMA moved for summary judgment, arguing that Frausto had failed to provide expert testimony as required by statute. In response, Frausto offered the sworn affidavit of Karen Wilkinson, an ARNP with more than 30 years of experience "providing direct patient care, serving as clinical nursing faculty for students providing care, and publishing nursing texts on the subject." Clerk's Papers at 127, 136-37. Wilkinson stated her "professional objective medical opinion, on a more probable than not basis, " that the treating nurses breached the applicable standard of care and that this breach proximately caused Frausto's pressure ulcers. Id. at 128.

         The trial court held that while Wilkinson was certainly qualified as an expert and could speak to the applicable standard of care, the law did not permit Wilkinson to testify on the issue of proximate cause. Frausto initially appealed to Division Three of the Court of Appeals but later moved to transfer the case to this court. Our commissioner granted the motion. Ruling Granting Mot. to Transfer, Frausto v. Yakima HMA, LLC, No. 93312-0 (Wash. Sept. 26, 2016).


         May an ARNP express an opinion on proximate cause in a medical malpractice case in accordance with RCW 7.70.040?


         Washington's statutory scheme creates several categories of care providers under the "nursing" umbrella-licensed practical nurses, registered nurses, and ARNPs-each with varying certification requirements and scopes of practice. See RCW 18.79.040-, 060. Our legislature has designated ARNPs as the highest tier of nurses, "prepared and qualified to assume primary responsibility and accountability for the care of patients" within the narrow scope of their particular certifications. RCW 18.79.050; WAC 246-840-300(1). We need consider the qualifications of only ARNPs for purposes of this case.

         Yakima HMA asserts first that we should review the trial court's ruling for abuse of discretion. Ordinarily, evidentiary rulings are a matter of discretion by the trial court and will not be upset on review absent an abuse of discretion, McKee v. Am. Home Prods. Corp., 113 Wn.2d 701, 706, 782 P.2d 1045 (1989). However, it is not clear that the trial court even attempted to exercise its discretion in resolving an evidentiary issue, believing instead that our case law foreclosed the possibility of Wilkinson's testimony on proximate cause. Verbatim Tr. of Proceedings (Oct. 21, 2015) (VTP) at 33 (noting that "the state of the law ... is that the nurse, no matter how well qualified, isn't capable of giving a decision on proximate cause"). In any event, "[t]he de novo standard of review is used by an appellate court when reviewing all trial court rulings made in conjunction with a summary judgment motion." Folsom v. Burger King, 135 Wn.2d 658, 663, 958 P.2d 301 (1998). Here, it is undisputed that the decision made by the trial court that is on review was made pursuant to Yakima HMA's motion for summary judgment. Because the trial court dismissed this case on summary judgment, our review is de novo. Aba Sheikh v. Choe, 156 Wn.2d 441, 447, 128 P.3d 574 (2006).

         In Washington, plaintiffs in a medical malpractice action must prove two key elements: (1) that the defendant health care provider failed to exercise the standard of care of a reasonably prudent health care provider in that same profession and (2) that such failure was a proximate cause of the plaintiffs injuries. RCW 7.70.040. With regard to the standard of care, we have repeatedly held that '"expert testimony will generally be necessary to establish the standard of care.'" Young v. Key Pharm., Inc., 112 Wn.2d 216, 228, 770 P.2d 182 (1989) (quoting Harris v. Groth, 99 Wn.2d 438, 449, 663 P.2d 113 (1983)). The expert must have "sufficient expertise in the relevant specialty" such that the expert is familiar with the procedure or medical problem at issue. Id. at 229.

         To establish causation, the plaintiff must show that the alleged breach of the standard of care "was a proximate cause of the injury complained of." RCW 7.70.040(2). Like the standard of care, expert testimony is always required except in those few situations where understanding causation "does not require technical medical expertise."[2] Young, 112 Wn.2d at 228 (giving the examples of "amputating the wrong limb or poking a patient in the eye while stitching a wound on the face"). "Whether an expert is qualified to testify is a determination within the discretion of the trial court." Miller v. Peterson, 42 Wn.App. 822, 832, 714 P.2d 695 (1986). In this case, however, the trial court did not believe it had any discretion to allow a nursing expert to testify regarding medical causation as a matter of law. VTP (Oct. 21, 2015) at 33.

         Although we have not opined on this specific issue, the Court of Appeals has offered conflicting analyses on this ...

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